<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Worker_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-worker_id" data-rule="required" data-source="worker/index" class="form-control selectpage" name="row[worker_id]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Order_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-order_id" data-rule="required" data-source="order/index" class="form-control selectpage" name="row[order_id]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('City')}:</label>
        <div class="col-xs-12 col-sm-8">
            <div class='control-relative'><input id="c-city" data-rule="required" class="form-control" data-toggle="city-picker" name="row[city]" type="text" value=""></div>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-code" data-rule="required" class="form-control" name="row[code]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Log_note')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-log_note" class="form-control " rows="5" name="row[log_note]" cols="50"></textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Log_attachment')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-log_attachment" class="form-control " rows="5" name="row[log_attachment]" cols="50"></textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Document_type')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-document_type" data-rule="required" class="form-control" name="row[document_type]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Document_no')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-document_no" data-rule="required" class="form-control" name="row[document_no]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Phone')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-phone" data-rule="required" class="form-control" name="row[phone]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Feedback')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-feedback" class="form-control " rows="5" name="row[feedback]" cols="50"></textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Hospital')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-hospital" data-rule="required" class="form-control" name="row[hospital]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Department')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-department" data-rule="required" class="form-control" name="row[department]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Doctor')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-doctor" data-rule="required" class="form-control" name="row[doctor]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Service_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-service_date" class="form-control" name="row[service_date]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-patient_name" data-rule="required" class="form-control" name="row[patient_name]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Worker_name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-worker_name" data-rule="required" class="form-control" name="row[worker_name]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Worker_arrive_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-worker_arrive_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[worker_arrive_time]" type="text" value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_arrive_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-patient_arrive_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[patient_arrive_time]" type="text" value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Diagnose_begin_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-diagnose_begin_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[diagnose_begin_time]" type="text" value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Diagnose_end_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-diagnose_end_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[diagnose_end_time]" type="text" value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Examine')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-examine" data-rule="required" class="form-control selectpicker" name="row[examine]">
                {foreach name="examineList" item="vo"}
                    <option value="{$key}" {in name="key" value="0"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Examine_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-examine_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[examine_time]" type="text" value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Examine_name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-examine_name" data-rule="required" class="form-control" name="row[examine_name]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medicine')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-medicine" data-rule="required" class="form-control selectpicker" name="row[medicine]">
                {foreach name="medicineList" item="vo"}
                    <option value="{$key}" {in name="key" value="0"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medicine_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medicine_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[medicine_time]" type="text" value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reexamine')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-reexamine" class="form-control selectpicker" name="row[reexamine]">
                {foreach name="reexamineList" item="vo"}
                    <option value="{$key}" {in name="key" value="0"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Result')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-result" class="form-control " rows="5" name="row[result]" cols="50"></textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_leave_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-patient_leave_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[patient_leave_time]" type="text" value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_unhappy')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-patient_unhappy" data-rule="required" class="form-control selectpicker" name="row[patient_unhappy]">
                {foreach name="patientUnhappyList" item="vo"}
                    <option value="{$key}" {in name="key" value="0"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Create_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-create_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[create_time]" type="text" value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
